DECIDUA POLYPOSA WITH ABNORMAL ADHESIONS* JULIUS LF.BOVITZ,
T HE decidual mucous membrane of the pregnant uterus may be the seat of many of the diseases that attack the endometrium of the nonpregnant uterus, with the exception that in the pregnant uterus the lesions and the histologic changes are modi:fied incident to pregnancy. They often manifest themselves, however, in an exaggerated form due to the enormous hyperplasia of the dee;_dual ~ndometrium, which is an exaggeration of hyperplasia which occurs normally in the early months of pregnancy, in which the decidua instead 9f becoming thinner, as is normally the ease, increases to considerable proportions. Another form of endometrial decidua change is the polypoid hyperplasia of the decidua. The decidua may show polyplike excrescences or projections of the entire hyperplastic endometrium or of limited areas. Virchow was :first to describe this condition in 1861, which he called decidua tuberosa and he considered it syphilitic in origin. In other eases, however, no cause whatsoever could be discovered, but probably there is a preexisting chronic endome· trial affection that would account for it. Schroeder also described this condition and observed that it usually ended in a miscarriage at the second or fourth month. Occasionally t}le prE>gnaney may be carried to term. Sometimes in abortion or labor the thickened decidua may cause abnormalities in the separation of the placenta and, incidentally, profuse hemorrhages. Nyulaey compiled about 100 cases. He believed that syphilis is an etiologic factor and also noticed disturbances in the separation of the placenta. Bulius holds, how· ever, that it occurs very rarely, and Williams stated that he has never seen such a case in his practice. To illustrate the abnormalities in the separation of the placenta and the result of the profuse bleeding, I desire to present this ease. Patient, aged thirty-:five years, family. history negative. She had had the usual childhood diseases. Moderate habits. She started to menstruate when twelve years old, and after menstruation was established, it recurred at twenty-eight-day intervals lasting from three to five days. No history of any disturbance at any time. She has one child seven years old which was delivered instrumentally after a rather difficult labor. The postpartum convalescence was prolonged. She stayed in the hospital eighteen days after delivery. No eoneeption for seven years. She was seen about the middle of February. The last menstruation was on Nov. 16, 1933. Upon bimanual examination, about a three months' pregnancy was found. On the twentieth of March, the patient gave a history of intermittent bleeding for thE' last five days, during which time she passed clots. On bimanual examination I found that the cervix was 2lh :fingers open, and the uterus was about the size of a four months' preg· nancy. Temperature 98.6°, pulse 84, no abdominal tenderness, moderate bleeding from the cervix. Patient was removed to the Midtown Hospital, whNe a curettage was performed under N.O + 0 2 anesthesia: The removed placenta was beet colored. The vagina was packed with iodoform gauze. The patient stayed in the hospital •Read before the Section on Obstetrics and Gynecology of the Medical Society of the County of Queens, April 19, 1935.
DECIDU A POI,YPOSA
aiJout four days; she had no temperature and made an uneventful recovery. She was discharged on the twenty-fourth of March. There was slight oozing for the iirst two days, after which it stopped. The pathologic report of the specimen is as fol· low~:
Microscopic section showed among the clots, bits of decidual cell as well ns nmn<>rous chorionic villi. Patient was well after this. About two months later her menstruation rt>tumed. 'l'he menstruation was very profuse and lasted about ten days. 't'he next menstrua· tion began about three weeks later and lasted about sixteen days. On bimanual examination the uterus was found in anteflexion, and was of normal size somewhat hardened. I advised a diagnostic curettage which the patieut declined. The follow· ing menstruation became more prolonged lasting from aixt<•en to twenty days, with short intermenstrual intervals, and there were just a few da;rs when patient was free from any bleeding. Finally patient consented to a diagnostic curettage, and on the eighteenth of August, 1934, she was again admitted to the Midtown Hospital. Ou curetting, in the right corner of the uterus I found a somewhat hardened mass about the size of a hazelnut; it was intimately adherent to the uterine wall, which upon curetting bled profusely. The vagina was packed with iodoform gauze. The path· ologic report of the curetting was as follows: Tissue consisted largely of placental tissue which underwent necrosis, and there were a few portions of endometrium with normal cells and rich stroma which were inftltrated by lymphoid cells. There was no evidence of malignant change of enrlo· metrium or placenta. After curetting, th~ patient stopped bleeding for the next four days. On the twenty-fourth of August the patient started to hemorrhage.. 'l'his raised the ques· tion of the diagnosis. My impression was that in spite of the negative pathologic re· port of this curetting, there was still the possibility of the existenre of a chorion· epithelioma or an intramural :fibroid on top of which a partial adherent placenta (~ould be present. In view of the ex!lessive hemorrhage I decided upon hysteredotny. By this time the patient's hemoglobin was down to 45 per cent and the red blood cf'lls down to two million. On August 24, I gave the patient a transfusion of 800 e.!l. of blood. The next morning I performed a supravaginal hysterectomy, under spinal anesthesia. Upon opening the abdomen I found the uterus in normal position somewhat enlarged and hardened; other pelvic organs were negative. When I opened the specimen I found a pol:ypoid cystic mass in the right corner of the uterus about the size of a hazelnut firmly attached to the uterine wall. The pathologic report a.bout this specimen was as follows: Gross.-Uterus measured 6 by 5 by 3 em. In the right eoruum was a polypoid mass measuring 1 by 5.1 em. attached to the mucosa and sharply delimited. It did not appear to invade the wall, although in one portion there was a fibrous e.ore ex· tending upward into the mass. On section, eut surface Bhowed numerous larw: hemorrhagic cysts. MkrosOQpic.-The polypoid mass consisted of organizing chori(Jnic villi firmly attached to the uterine walls, but not filtrated. The blood spaces were tremendously dilated and contained early clots. This region was sharply delimit.ed from the adjacent endometrium. At the edge the endometrium had very markedly dilated glands, but this changed very rapidly to the normal endometrium found over the remainder of the uterine cavity. The uterine wall had a moderately diffuse :fibrosis. 1'he serosal surface was normal. There '\YlHl no evidence of n::alignaney either in the placental remains or in the endometrium.
AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY
Patient made an uneventful recovery and stayed in the hospital about ten days and is at present feeling well. This case is interesting from the point of view that all possible abnormalities that a decidua polyposa could present were present in this ease, such as interruption of pregnancy, abnormal adherency of the placenta, and profuse hemorrhages. 49-20 FoRTY:THIRD AVENUE
MYXOFIBROSARCOMA OF THE OV.ARY*
c. H. HIXSON, M.D., wASHINGTON, D. c. HE patient (Columbia Hospital, Case 70629) was a white female, aged twenty· T nine years, had been married but now separated. She came into the hospital com· plaining of enlargement of the abdomen and gave the following history. On April 26, 1934, she noticed a hard, tender lump in her abdomen. A short time later, she began to have pains in her baek. Her abdomen continued to enlarge and the mass had reached the umbilicus when she entered the hospital on Aug. 71 1934. She did not have any symptoms of pregnancy except an amenorrhea. Her last menstrual period was about April 7 and the period previous was about a year ago. Her men· struation began when she was ten years old, with an interval of from twenty-one to twenty-eight days, and a duration of seven days. Until about a year ago her periods were regular. She had one pregnancy seven years ago, which was nonnal. There has been frequency of urination for the past two years. There was no history of previous operations or serious illnesses. Physical examination revealed a fairly well-nourished female with a normal temperature, pulse, and respiration. General physical examination was essentially negative. The abdomen contained a large, firm, tender and slightly movable mass extending to the umbilicus which, on vaginal examination was found nearly filling the pelvis. It was diagnosed as a leiomyoma of the uterus. She was operated upon on the ninth of August and found to have a large tumor of the right ovary, adherent to the uterus, which was pushed backward and to the left. The adhesions were separated easily, and the tumor was dissected from its peritoneal covering and removed together with the tube. The pathologic report was: Gros8 Examina.tion.-The specimen was a large, relatively soft ovarian tumor, measuring 17 by 16 by 10 em. in its greatest dimensions. The sectioned surfaces were very moist, glistening, and soft with multiple cystic cavities :filled with clear :duid. Micro8copic Examination.-The tumor was composed of very small spindle· and stellate-shaped cells with small, dense, irregularly shaped nuclei and fairly evenly distributed nuclear chromatin. The cytoplasmic boundaries were indistinct, and there was a considerable amount of loose fibrillar intercellular stroma. In some areas the myxomatous appearance was more prominent than in others. Mitoses were relatively infrequent. Diagnosi8.-Myxo:fibrosarcoma. Although the histologic appearance of this tumor was that of a :fibrosarcoma with myxomatous degeneration, the clinical course should be favorable unless adhesions were present. If the tumor was adherent to the surrounding structures local recur· renee may be expected. •Presented at a meeting of the Washington Gynecological Society, 1935.